This case is thefourth in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil.
Dr. Rebecca Shaw is an emergency physician currently working as a Medical Education Fellow within the Emergency department of the Gold Coast Hospital and Health Service in Queensland, Australia. Dr. Nemat Alsaba (@talk2nemat) is an Emergency physician with a special interest in Geriatric Emergency Medicine, medical education and simulation. She is trying her best to combine these interests to improve Geriatric patient care across all health sectors. She is also an Assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com).
Why it Matters
Elderly patients requiring resuscitation are frequently encountered in the ED. When patients are non-communicative, close family members are regularly required to act as substitute decision makers and represent their family member’s wishes. Engaging and communicating effectively with SDMs in end-of-life and goals-of-care discussions is necessary to provide the most appropriate care for the elderly patient. This case gives the opportunity to learn and enhance these skills.
Clinical Vignette
The charge nurse informs you “I just put a very unwell looking patient into resus. She’s from a nursing home facility and the paramedics think she is septic. She’s hypotensive and barely responsive. Honestly, she looks like she might be dying. Her granddaughter is on her way. I don’t think she has a known advanced care directive or code status.”
Case Summary
An 89-year-old patient is brought in to the ED by ambulance from their nursing home. Staff found her unresponsive and hypotensive at morning handover. She had been treated for UTI by her family physician over the last few days. Participants identify severe sepsis and realize that critical care interventions may be inappropriate. This should prompt a goals of care discussion including potential for initiating end-of-life care.
Written by Sonja Wakeling. Edited by Dr. Teresa Chan.
Everything I know about ED management I learned from… A Board Game?
GridlockED is an innovative board game that fosters teamwork, knowledge acquisition and application, and problem-solving skills. Developed by clinician educators and trainees, it was designed to simulate real-life settings in an emergency department within a risk-free learning environment. In the healthcare field, it is impossible to allow junior learners full reign of an emergency department, yet they require some level of experience if they are to be responsible and effective when they are practicing and learning. It is imperative that learners exercise and develop skills in a variety of required domains, such as the Royal College of Physicians and Surgeons of Canada’s CanMEDs qualities; these include communication, collaboration, health leadership, health advocacy, scholarship, and professionalism..(1)
Learners acquire knowledge in a variety of approaches, traditionally through didactic lectures but also through other more interactive methods. There has been an important shift from classic knowledge dissemination to more active participation(2); however, finding novel ways to provide both effective and efficient acquisition assists in training a highly-qualified generation of new physicians. In recent years, there has been a surge of simulation-based learning in medical education, particularly at the level of post-graduate and undergraduate medical training.(3) Multiple studies have shown that simulations are an effective method of education; for example, increasing the learner’s confidence in addition to increasing knowledge retention both short- and long-term.(4)
GridlockED: a serious game for learners
Serious games, which Bergeron defines as an “interactive computer application, with or without significant hardware components”, are a form of simulations.(5) Instead of being designed with a set of primary winning objectives, their main objective is for the player to acquire knowledge and skills in a challenging and fun learning environment; in a situation like this, the knowledge is seemingly acquired with little effort.(6) This method of learning has recently taken off in residency education, as evidenced by the systematic review of serious gaming within the surgical field(6); however, there is limited evidence to support their utility given that the expanding use of serious gaming as a relatively new approach to medical education. This is one such area that require intensive and thorough research as a means of advancing effective teaching methods in medical education.
In the context of disaster preparedness, tabletop exercises and simulations have been a key aspect of their planning and preparations.(7)GridlockED is an example of a serious game that employs a tabletop simulation approach, which Agboola an colleagues described as one that “involves key personnel discussing simulated scenarios in an informal setting based on existing operational plans and identifying where those plans need to be refined.”(7) GridlockED can accommodate up to 6 participants, given that it is a co-operative and collaborative style of play, whose purpose is to collaborate and reason through the management of patients during a “standard” 8-hour shift in an emergency department. For those with ample professional experience, this task certainly may not seem difficult; however, as a junior learner it sets a great challenge to efficiently and intelligently manage the flow of patients.
Objectives and templates: GridlockED as a teaching tool
So, what makes GridlockED a valuable teaching tool? This low-stakes learning
environment allows participants the opportunity to discuss various approaches,
make mistakes (and more importantly, to learn from them), and come to
understand how they might prioritize certain patients or tasks in a busy
emergency department. The point is not to acquire knowledge around diseases or
illness management, but rather the skill to lead and collaborate in a mission
to provide effective care (and ultimately “win” the game). The beauty of this
game is that this is all done outside of the department where there are no real
patients, and where entrusted facilitators can help provoke discussion around
challenges, successes, and errors.
In addition to the basic gameplay set-up, learning templates are being developed that focus on themed settings or situations that promote particular clinical lessons. For example, there is one theme that results in a shortage of nursing staff, forcing participants to adjust their gameplay style and therefore clinical management akin to a similar situation in a real emergency department. Another theme places you in a rural emergency department with limited resources including staff and specialists available to assist you. Furthermore, an additional template fills your department with patients, taking the game title GridlockED to a serious level. Each teaching template is led by a facilitator who helps the team delve into the decisions they make and reflect on methods to improve their future management.
As a junior learner myself, I have taken
some key learning points away from each round of GridlockED I have participated in; for example, never forget the bigger picture. The
game allows you to slow down for a moment and view the whole “picture” of the
department. Here, you can keep a watchful eye on both patient flow and volume,
consider the challenges you are currently facing, and what you foresee may
occur. Layer on top of this basic gameplay with various themed learning
templates and you have yourself a robust and effective teaching tool that is
also fun to engage in!
But there are many more valuable learning
points I have taken away from each cycle of gameplay lend themselves to the
management of a real emergency department.
Plan ahead. It is not a good idea to leave your high acuity beds with unstable patients in them, unless you have absolutely no choice. If you cannot care for the next patient who comes in in serious condition because your beds are blocked, you (and that patient) are in trouble. And related to that, strategize to maximize the efficiency in each zone of the department.
Prioritize sick patients. Despite patients expressing concern about wait times, there are instances where it is reasonable and indeed appropriate to delay care of low-acuity patients in favour of those who are in serious condition. If someone is waiting in an emergency department, and given the limitations of the healthcare system, it is often a good sign; that individual is not dying or in critical condition, so it means there are other patients who require more immediate attention. That is not a position anyone wants to be in, so try to wait with patience and gratitude.
Collaborate inter-professionally. There are various roles to be played, including nursing, specialties, and learners. However, each participant playing may have a different role in the real world. Rely on their knowledge and experience, and listen to what they say. The most effective leaders know when to lead and also when to listen.
Speaking of collaboration, do not forget
the limitations of each allied health or specialty role. Recognize when a
professional may be in over their head and help where you can. Only so many
blood vials or imaging results can be completed in a fixed amount of time. Be patient, be mindful, and have reasonable
expectations.
At the end of the day, do what is best for the patients being
treated. See as many patients as you can, treat as many as you can, and do
your best to save everyone you can. Sometimes you cannot save everyone, but
learn from each experience you have so you improve the situation for the next
time you have a similar scenario.
Now that you know what is at stake… Are you up for the challenge?
GridlockED was developed by staff physicians and medical students at McMaster University in Hamilton, Ontario, Canada. Please visit https://gridlockedgame.com if you would like to learn more or purchase the game. All proceeds for the game go towards fostering further education and scholarly projects at McMaster University.
Allerly LA. Educational games and structured experiences. Med Teach. 2004 Sep;26(6):504-5.
Bradley P. The history of simulation in medical education and possible future directions. Med Educ. 2006 Mar;40(3):254-62.
Behar S, Upperman JS, Ramirez M, Dorey F, Nager A. Training medical staff for pediatric disaster victims: a comparison of different teaching methods. Am J Disaster Med. 2008 Jul-Aug;3(4):189-99.
Bergeron BP. Developing Serious Games. Charles River Media: Hingham, 2006.
Graafland M, Schraagen JM, Schijven MP. Systematic review of serious games for medical education and surgical skills training. Br J Surg. 2012;99:1322-1330.
Agboola F, McCarthy T, Biddinger PD. Impact of emergency preparedness exercise on performance. J Public Health Manag Pract. 2013 Sep-Oct;19 Suppl 2:S77-83.
Today’s piece is written by Dr. Lall. She is an Associate Professor and Associate Residency Director of Emergency Medicine at Emory University in Atlanta, GA. She is also the current president of the Academy for Women in Academic Emergency Medicine. Dr. Lall’s research focuses include physician wellness and gender bias and inequity in medicine. The following is a summary of her recent publication on this issue.
You can find the publication here:
Jeffrey N. Siegelman, Michelle Lall, Lindsay Lee, Tim P. Moran, Joshua Wallenstein, and Bijal Shah (2018) Gender Bias in Simulation-Based Assessments of Emergency Medicine Residents. Journal of Graduate Medical Education: August 2018, Vol. 10, No. 4, pp. 411-415.
Background:
There is a paucity of studies on gender differences in milestone assessment. One recent large multi-site cohort study of EM residents evaluated bias in end-of shift evaluations and found a significant bias based on resident gender (Dayal A et al, 2017). Shift evaluations usually represent subjective assessments and residents are evaluated only on cases seen during a particular shift, resulting in considerable variation with respect to which competencies are assessed across residents and rated by faculty. Simulation allows for a more structured, consistent evaluation environment in which residents can be tested on identical clinical problems, and in which specific competencies can be assessed. We hypothesized that simulation, being a more objective assessment tool, may mitigate gender disparities in resident assessment.
In our three year experience with biannual milestone-based simulation assessments of all our EM residents, no significant gender bias was observed in contrast to other forms of resident assessments, such as end-of-shift evaluations.
Tips for SIM Educators:
Training the standardized patient is key to successful simulation assessment.
Pilot test the scenarios to ensure the case plays as expected and appropriately elicits the opportunity for the resident to perform the desired critical behaviors.
Evaluate for potential bias introduced by the standardized patient script or actions as the scenario plays out.
Ensure that standardized patient responses are the same every time.
Same response in the same tone of voice with the same facial expressions whether the physician is male or female.
Standardized patient script cues should be written with binary language.
If the resident does not introduce themself to the patient, prompt the resident with “Doctor, what is your name?”
Avoid language like miss, ma’am or sir
Education and training of the rater is of critical importance.
Raters should be instructed that evaluation in these cases is not subjective. Evaluation is binary and based on observable behavior only.
Convert milestone language into binary, observable behaviors
Assessment items should avoid language that may introduce bias including subjective assessments.
Agenic adjectives: typically used to describe men and when used to describe women carry a negative connotation. Examples include assertive, autonomous, independent, confident, intellectual.
Communal adjectives: typically used to describe women and when not demonstrated by women carry a negative connotation. Examples include kind, compassionate, sympathetic, warm, helpful.
Focus on action based assessment items, for example:
Resident introduced themself to the patient
Resident updated the family using lay terminology
Resident ordered magnesium without prompting
Checklist for Limiting Bias in Simulation Assessment
Standardize the Scenario
Standardized patient/Confederate scripting and training is crucial
Simulation operator training
Pilot the case
Create an Objective Rating Tool
Focus on observable behaviors rather than subjective assessments
Observed/ Not Observed/ Unable to Assess
Train the raters
Use language that avoids bias
Monitor for bias
Analyze data after an assessment for validity evidence, reliability, and evidence of bias
This case is the third in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil.
Dr. Rebecca Shaw is an emergency physician currently working as a Medical Education Fellow within the Emergency department of the Gold Coast Hospital and Health Service in Queensland, Australia. Dr. Nemat Alsaba (@talk2nemat) is an Emergency physician with a special interest in Geriatric Emergency Medicine, medical education and simulation. She is trying her best to combine these interests to improve Geriatric patient care across all health sectors. She is also an Assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com).
Why it Matters
Deciding when to terminate CPR is a very delicate moment in a patient’s care. It is literally the determination of possible life vs. certain death. There are clear guidelines for when to terminate resuscitation in certain contexts, but for patients who are brought to the ED by EMS, there is no true objective measure of when to terminate CPR. This is where determination of quality of life is important. In the elderly, the likelihood of a meaningful quality of life after a CPR-requiring event is quite low. Recognizing this futility is an important and challenging skill to learn. Being able to debrief with your team and discuss these events further is another essential skill that is often not practiced. This case gives the opportunity to learn and enhance these skills.
Clinical Vignette
ED RN to inform team prior to patient’s arrival: “We have an out of hospital cardiac arrest coming in with an unknown downtime and unknown past medical history. He is an 89-year-old male coming from home. He has had no shocks and CPR is in progress. They are one minute away.”
Case Summary
An elderly male is brought in by ambulance from home with CPR in progress. He collapsed in front of his son/daughter who commenced CPR. His rhythm has been PEA throughout and his downtime is 20 minutes. Participants should assess the patient, gather information about his background and determine that CPR is futile. They should decide to cease CPR and inform his son/daughter in a sensitive manner that their father has died. They will also debrief the team following the termination of resuscitation.
This case is the second in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Rebecca Shaw, Nemat Alsaba, and Victoria Brazil.
Dr. Rebecca Shaw is an emergency physician currently working as a Medical Education Fellow within the Emergency department of the Gold Coast Hospital and Health Service in Queensland, Australia.Dr. Nemat Alsaba (@talk2nemat) is an Emergency physician with a special interest in Geriatric Emergency Medicine, medical education and simulation. She is trying her best to combine these interests to improve Geriatric patient care across all health sectors. She is also an Assistant professor in medical education and simulation at Bond university. Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com).
Why it Matters
This case demonstrates several diagnostic challenges that can occur with the bradycardic patient on digoxin including:
The need to resuscitate the patient appropriately (and thus, empirically treat) while waiting on labs to confirm whether hyperkalemia or digoxin is the culprit
The theoretical concern of administering calcium for correction of hyperkalemia (because we usually have a potassium result back before the digoxin level)
The need to consider precipitating causes of a patient’s presentation
Clinical Vignette
To be stated by the bedside nurse: “Bertie is an 85-year-old man who has been brought in after a fall at home. He says he is feeling dizzy and has a HR of 30 on the monitor. I haven’t had much of a chance to take more of a history from him but he has a list of medications with him and seems ok from the fall other than a bruise on his head.”
Case Summary
An 85-year-old man presents after a fall at home. He is complaining of dizziness and has a HR of 30. Further assessment reveals chronic digoxin toxicity and a concurrent UTI with acute renal failure. The patient requires management of his bradycardia and acute renal failure with specific management of chronic digoxin toxicity including a discussion with toxicology and administration of Digibind.
This case is the first in a six-part mini-series focusing on the management of geriatric patients in the ED. This series of cases was written by Drs. Victoria Brazil, Nemat Alsaba, and Rebecca Shaw.
Dr. Victoria Brazil is an emergency physician and medical educator. She is Professor of Emergency Medicine and Director of Simulation at the Gold Coast Health Service, and at Bond University medical program. Victoria’s main interests are in connecting education with patient care – through healthcare simulation, technology enabled learning, faculty development activities, and talking at conferences. Victoria is an enthusiast in the social media and #FOAMed world (@SocraticEM), and she is co-producer of Simulcast (Simulationpodcast.com). Dr. Nemat Alsaba (@talk2nemat) is an Emergency physician with a special interest in Geriatric Emergency Medicine, medical education and simulation. She is trying her best to combine these interests to improve Geriatric patient care across all health sectors. She is also an Assistant professor in medical education and simulation at Bond university. Dr. Rebecca Shaw is an emergency physician currently working as a Medical Education Fellow within the Emergency department of the Gold Coast Hospital and Health Service in Queensland, Australia.
Why it Matters
As our global patient population ages, it is increasingly important that emergency physicians have specialized knowledge in the care of elderly patients. This is particularly true when managing patients with baseline dementia or presenting to the ED with delirium. This case highlights specific challenges in these patients, including:
The need to recognize delirium as symptom of a large array of potential medical illnesses
The importance of a medical work-up in patients with delirium (including blood work, urine, and possible imaging)
The need for health care workers to have a toolbox of de-escalation techniques at their disposal
Clinical Vignette
Patient is sitting on the edge of the ED bed, looking perplexed. She/he is fidgeting and not concentrating on the questions being asked, she/he is staring around the room, looking in his/her bag and picking at the BP cuff and bed sheet. The ED nurse is attempting to do some baseline vital signs on the patient.
Participants asked by ED RN “Could you please go and assess this patient? She/he has just been brought in to the ED by ambulance after a friend found her/him confused at home”
Case Summary
An 81-year-old (wo)man is brought to the ED by her/his friend as she/he is confused and agitated. In the ED, her/his confusion worsens. Initially she/he is fidgety but as the case progresses she/he becomes more agitated and confused. She/he will be fairly uncooperative, moving around and not able to follow many commands. The participants should be looking for a source of infection and evidence of any recent trauma. They are expected to use both non-pharmacological and safe pharmacological options in order to control the situation, ensure patient safety, and facilitate investigations.
This week’s case is written by Drs. Ashley Lubberdink and Sameer Sharif. Dr. Lubberdink is a PGY4 Emergency Medicine resident at McMaster University and is just beginning her fellowship in simulation and medical education. Dr. Sharif is a PGY5 Emergency Medicine resident at McMaster University who has just completed his fellowship in simulation and medical education.
Why it Matters
LVADs are pretty uncommon devices! If your practice location is not a hospital that inserts LVADs, then it is likely that you have never come across a patient with an LVAD. Without prior knowledge of these devices, it can be quite distressing trying to assess these patients. This case is designing to highlight the following:
LVAD patients do not have a pulse, a measurable blood pressure, or a detectable heart rate on the sat probe
To assess for blood pressure, one must insert an arterial line or use a blood pressure cuff and doppler U/S to obtain the MAP
Early after LVAD placement, drive line infection and bleeding are common complications
Call for help early! These patients generally have care providers who are available to help trouble shoot by phone at all hours of the day
More Reading
For more information on an approach to LVADs, we suggest the following sources:
A 62-year-old male presents to your large community ED with a 1 day history of generalized malaise and nausea and a 2-hour history of palpitations. He is particularly concerned about his symptoms because last month he had an LVAD placed at your provinces’ major cardiac center (3 hours away) for stage 4 CHF. His wife is accompanying him but is currently parking the car.
Case Summary
A 62-year-old man presents to the ED with palpitations and general malaise. On initial assessment, the team finds out he had an LVAD placed within the last 1 month. The team will need to work through how to assess the patient’s vital signs appropriately and will discover the patient has a low MAP and a low-grade fever. On inspection, the patient’s drive line site will appear infected. The initial ECG will show features of hyperkalemia. After the initial assessment, the patient will progress to a PEA arrest requiring resuscitation by ACLS protocols. Labs will reveal an acute kidney injury and hyperkalemia. The patient will obtain ROSC when the hyperkalemia is treated.
This case is written by Dr. Chris Heyd. He is a PGY4 Emergency Medicine resident at McMaster University and has spent the last year completing a sub-specialty focus in disaster medicine and simulation. He is also one of our resident editors here at EmSimCases.
Why it Matters
This case highlights some of the challenges that can be associated with activating a trauma team. While the intent is to have many expert hands available to help at once, sometimes the team members arrive in a staggered fashion. This case reviews:
The challenges of managing an unstable trauma patient when there are interruptions to the flow of communication
The need to expediently place a chest tube in a hypoxic trauma patient
The fact that near simultaneous intubation and chest tube placement is often necessary in an unstable trauma patient
Clinical Vignette
To be read aloud by simulation facilitator at start of case:
“You are working as an Emergency physician at a tertiary care trauma centre and have been called overhead to your trauma bay. A paramedic team has just arrived with a 64-year old trauma patient. He was involved in a highway speed head-on MVC. He was restrained and air bags deployed. He was the driver and the other drive died on scene. There were no other passengers. EMS extricated the patient easily. They have placed one IV line and started running normal saline. He has been placed on a non-rebreather mask but has remained tachycardic, hypoxic and altered. GCS has been consistently 14. The trauma team was activated based on injury mechanism but so far only the orthopedic resident has arrived at the bedside.”
Case Summary
A 64-year old man is involved in a high-speed car crash. The trauma team is activated and he is brought directly to the ED. On arrival, he is hypoxic, tachycardic and altered. CXR reveals multiple rib fractures with a right-sided hemopneumothorax.
The team leader will need to effectively communicate with the team to ensure the tasks of intubation, chest tube placement and blood product administration are performed in a safe and quickly. The patient will stabilize after these treatments.
Members of the trauma team will have a staggered entry into the room. The team leader will need to balance communication with the new team members and the urgent interventions needed by the patient.
This case is written by Drs. Nadia Primiani and Sev Perelman. They are both emergency physicians at Mount Sinai Hospital in Toronto. Dr. Primiani is the postgraduate education coordinator at the Schwartz/Reisman Emergency Centre. Dr. Perelman is the director of SIMSinai.
Why it Matters
Most emergency physicians have some degree of discomfort when a woman in her third trimester presents to the ED for any complaint. When that woman presents in acute distress, the discomfort is increased even further! This case takes learners through the management of a patient with a pregnancy-induced cardiomyopathy, reviewing:
The importance of calling for help early
The fact that all pregnant patients at term must be presumed to have difficult airways
That the treatment of the underlying medical condition is still the primary focus – in this case, BiPap, definitive airway management, and ultimately, inotropic support
Clinical Vignette
You are working in a community ED and your team has been called urgently by the nurse to see a 38 year old female who is G2P1 at 36 weeks gestational age. She was brought in by her sister, who is quite agitated and upset, saying “everybody has been ignoring her symptoms for the last 4 weeks.” The patient has just experienced a syncopal episode at home.
Case Summary
A 38-year-old female G2P1 at 36 weeks GA presents with acute on chronic respiratory distress in addition to chronic peripheral edema. She undergoes respiratory fatigue and hypoxia requiring intubation. She then becomes hypotensive which the team discovers is secondary to cardiogenic shock, requiring vasopressor infusion and consultation with Cardiology/ ICU.
This case is written by Drs. Laura Simone and Olivia Ostrow. They are both Pediatric Emergency Physicians at Toronto’s Sick Kids Hospital.
Why it Matters
SVT is the most common pediatric dysrhythmia that we see in the ED after sinus tachycardia. But sometimes, in very young children and infants, it can be hard to distinguish the two! This case highlights some important features of the management of SVT, including:
The need for an ECG when they heart rate is very high
The role of vagal maneuvers as a first attempt at cardioversion
The dosing of adenosine and electricity for cardioversion of SVT
Clinical Vignette
A 12-month old male is brought into your ED today by his parents because he has been fussy, crying all night and not feeding well today. He had emesis x 1 (non-bilious, non-bloody). At triage, the RN had difficulty recording the heart rate but by auscultation it seemed “quite rapid” and he “feels a bit warm”.
Case Summary
The team has been called to the ED after a 12-month old is brought in with a rapid heart rate. The team will realize the patient is in a stable SVT rhythm, with no response to either vagal maneuvers or adenosine. The patient will then progress to having an unstable SVT. If the SVT is defibrillated (i.e. – shocked without synchronization), the patient will progress to VT arrest. If the SVT is cardioverted, the patient will clinically improve.
(ECG source: 
